[Sedation for Endoscopy at SMC Endoscopy Unit]

1. ASA classification

Class I The patient is normal and healthy.
Class II The patient has mild systemic disease that does not limit their activities. e.g., controlled hypertension or DM without complications.
Class III The patient has moderate or severe systemic disease, which does limit their activities. e.g., stable angina or DM with complications.
Class IV The patient has severe systemic disease that is a constant potential threat to life. e.g., congestive heart failure, chronic renal failure.
Class V The patient is morbid and is at substantial risk of death within 24 hours.
Class E Emergency stats: in addition to indicating underlying ASA status (I-V), any patient undergoing an emergency procedure is indicated by the suffix "E".


2. Initial dose for upper endoscopy

Condition Body weight >= 60 kg Body weight < 60 kg
Age < 65 years Midazolam 2.5 mg Midazolam 2 mg
Age >= 65 years Midazolam 2 mg Midazolam 1.5 mg

@ Pethidine 25 mg IV may be used for selected patients with age < 70 years.


3. Initial dose for colonoscopy

Condition Body weight >= 60 kg Body weight < 60 kg
Age < 65 years Midazolam 2.5 mg + Pethidine 25 mg Midazolam 2 mg + Pethidine 25 mg
Age >= 65 years Midazolam 2 mg + Pethidine 25 mg Midazolam 1.5 mg + Pethidine 25 mg


4. Additional dose

1. Wait for at least 2-3 minutes after the initial dose.

2. If necessary, add midazolam 0.5 mg (age >= 65 years) or 1 mg (age < 65 years).

3. Interval for the next dose should be at least 1-2 minute.

4. Additional pethidine needs to be individualized (used only rarely).


5. Level of sedation

Three level system (mild/moderate/deep) is recommended for the monitoring of sedation level [ASA method]. Old system of Richmond agitation sedation scale (RASS) is not used anymore. If paradoxical response is observed, it should be recorded separately.

□ minimal (최소 진정): 약물에 의해 불안이 해소된 상태로 구두지시에 정상적으로 반응함. 인지기능과 조화기능의 저하가 관찰될 수 있으나 자발 환기와 심혈관계기능은 정상임.

□ moderate (중등도 진정): 약물에 의해 의식이 저하된 상태로 구두지시나 가벼운 접촉자극에 의미있는 반응을 보임. 적절한 자발 환기를 보이며 심혈관계 기능은 유지됨.

□ deep (깊은 진정): 약물에 의해 쉽게 깨지 않는 상태로 반복된 자극이나 의도적인 통증 자극에 단순 회피 반응 정도만 보임. 적절한 기도유지와 자발 환기를 위한 보조가 필요할 수 있으나, 심혈관계 기능은 대부분 유지됨.


□ paradoxical response : 약물에 투여 후 오히려 흥분과 불안을 보이며, 구두지시나 자극에 통제되지 않는 모순된 반응을 보임.


6. Midazolam sedation for ESD (이준행)

1. Initial sedation dose

Condition Body weight >= 60 kg Body weight < 60 kg
Age < 65 years Midazolam 3 mg + Pethidine 25 mg Midazolam 2 mg + Pethidine 25 mg
Age >= 65 years Midazolam 2 mg + Pethidine 25 mg Midazolam 1 mg + Pethidine 25 mg

2. Wait for at least 3 minutes after the initial dose.

3. If necessary, add midazolam 0.5 mg (age >= 65 years) or 1 mg (age < 65 years).

4. If necessary, add Pethidine 25 mg.


7. Further reading

1. Sedation에 대한 상세한 설명

2. Related topics in EndoTODAY

3. Multisociety sedation curriculum

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